Introduction



9144001143000PATIENT EXPERIENCE AT UPMC CHILDREN’S HOSPITAL OF PITTSBURGH AMBULATORY DEPARTMENTbyManasa PallapoluB.S. Health Sciences, Drexel University, 2016Submitted to the Graduate Faculty ofHealth Policy and ManagementGraduate School of Public Health in partial fulfillment of the requirements for the degree ofMaster of Health AdministrationUniversity of Pittsburgh201900PATIENT EXPERIENCE AT UPMC CHILDREN’S HOSPITAL OF PITTSBURGH AMBULATORY DEPARTMENTbyManasa PallapoluB.S. Health Sciences, Drexel University, 2016Submitted to the Graduate Faculty ofHealth Policy and ManagementGraduate School of Public Health in partial fulfillment of the requirements for the degree ofMaster of Health AdministrationUniversity of Pittsburgh2019914400114300UNIVERSITY OF PITTSBURGHGRADUATE SCHOOL OF PUBLIC HEALTHThis essay is submittedByManasa PallapoluonApril 17, 2019and approved byEssay Advisor:Samuel Friede, MBA, FACHEAssistant ProfessorDepartment of Health Policy & ManagementGraduate School of Public HealthUniversity of PittsburghEssay Readers:Martha Ann Terry, PhDAssociate ProfessorDirector, MPH ProgramBehavioral and Community Health SciencesGraduate School of Public HealthUniversity of PittsburghAlexandra Lackos, MHADirector, Satellite and Outreach ServicesDivision Administrator, Newborn MedicineUPMC Children’s Hospital of Pittsburgh00UNIVERSITY OF PITTSBURGHGRADUATE SCHOOL OF PUBLIC HEALTHThis essay is submittedByManasa PallapoluonApril 17, 2019and approved byEssay Advisor:Samuel Friede, MBA, FACHEAssistant ProfessorDepartment of Health Policy & ManagementGraduate School of Public HealthUniversity of PittsburghEssay Readers:Martha Ann Terry, PhDAssociate ProfessorDirector, MPH ProgramBehavioral and Community Health SciencesGraduate School of Public HealthUniversity of PittsburghAlexandra Lackos, MHADirector, Satellite and Outreach ServicesDivision Administrator, Newborn MedicineUPMC Children’s Hospital of Pittsburghcenter4648200Copyright ? by Manasa Pallapolu201900Copyright ? by Manasa Pallapolu2019center-222250Samuel Friede, MBA, FACHEPATIENT EXPERIENCE AT UPMC CHILDREN’S HOSPITAL OF PITTSBURGH AMBULATORY DEPARTMENTManasa Pallapolu, MHAUniversity of Pittsburgh, 201900Samuel Friede, MBA, FACHEPATIENT EXPERIENCE AT UPMC CHILDREN’S HOSPITAL OF PITTSBURGH AMBULATORY DEPARTMENTManasa Pallapolu, MHAUniversity of Pittsburgh, 2019ABSTRACTIn healthcare, there is a push towards value-based payment model instead of the fee-for-service model that has been utilized. Healthcare organizations are expected to survey their patients in order to receive maximum payments from payers. Along with payment, providers and hospitals are being compared to each other so there is additional pressure to improve the patient experience to increase patient volume. Patients, for the most part, have the opportunity to pick their provider and health facility so they are more likely to pick the option that yields better results. The Agency for Healthcare Research and Quality (AHRQ) oversees the Consumer Assessment of Healthcare Providers and Systems (CAHPS). AHRQ’s goal is to have standardized surveys that are distributed to providers in order to effectively compare providers to each other. UPMC Children’s Hospital of Pittsburgh is one of more than 40 hospitals in the University of Pittsburgh Medical Center (UPMC) system. Its Ambulatory Department is utilizing the CAHPS Clinical & Group Survey and Press Ganey Associated Inc. to gather unbiased feedback from patients. The Ambulatory Department leadership team is consistently assessing its department for areas for improvement. Currently, the department is working towards a variety of initiatives aimed at improving the patient experience including utilizing medical scribes, a centralizing their call center and improving space utilization. The author assessed current patient satisfaction scores and how they compare nationally and recommended potential areas for improvement. The recommendations include rounding on patients, coaching for increasing staff engagement and setting expectations for staff behavior. Overall, UPMC Children’s Hospital of Pittsburgh is making large strides to improving the overall experience of their patients and families. The public health significance of patient experience is that it is a part of the Institute for Healthcare Improvement Triple Aim and correlated to higher quality of care. The Triple Aim is a framework that optimizes the health system performance and incorporates improving the patient experience and improving health of the population and reducing the cost of healthcare. TABLE OF CONTENTS TOC \o "2-4" \h \z \t "Heading 1,1,Appendix,1,Heading,1" 1.0Introduction PAGEREF _Toc7087623 \h 11.1Consumer assessment of healthcare providers and systems (CAHPS) PAGEREF _Toc7087624 \h 21.2Survey Delivery PAGEREF _Toc7087625 \h 32.0Literature Review PAGEREF _Toc7087626 \h 63.0Case Study: UPMC Children’s Hospital of Pittsburgh PAGEREF _Toc7087627 \h 83.1Current Scores PAGEREF _Toc7087628 \h 83.2Current initatives PAGEREF _Toc7087629 \h 103.2.1Wait Times PAGEREF _Toc7087630 \h 103.2.2Scribes PAGEREF _Toc7087631 \h 113.2.3Call Center PAGEREF _Toc7087632 \h 123.2.4Provider Gap Analysis PAGEREF _Toc7087633 \h 133.2.5Patient Experience Reporting PAGEREF _Toc7087634 \h 143.2.6AIDET Plus the Promise PAGEREF _Toc7087635 \h 164.0Recommendations PAGEREF _Toc7087636 \h 174.1.1Patient Experience Coach PAGEREF _Toc7087637 \h 174.1.2Leadership Rounding PAGEREF _Toc7087638 \h 184.1.3Increase Front Line Staff Engagement PAGEREF _Toc7087639 \h 184.1.4Setting Expectations PAGEREF _Toc7087640 \h 195.0Conclusion PAGEREF _Toc7087641 \h 21bibliography PAGEREF _Toc7087642 \h 23List of figures TOC \h \z \c "Figure" Figure 1: CY 2018 Patient Experience Scores PAGEREF _Toc5794629 \h 7Figure 2: Overall Doctor Rating of 9 - 10 graph PAGEREF _Toc5794630 \h 12IntroductionHealthcare is constantly evolving with new improvements and initiatives that are transforming the overall patient experience. Currently, there is a shift from volume to value-based care, which requires providing the best patient experience possible. The patient experience includes all of the interactions that patients and families have with their health system. This includes any interaction with a provider or front line staff. Patient satisfaction and experience are often used interchangeably in conversation; however, they are different. Patient satisfaction is about whether the provider is meeting the expectations of the patient, while the patient experience is about the whole visit. The healthcare organization’s expectation is to satisfy a patient. Ensuring that patients have a positive experience as a whole is what will bring the patients back to the same provider for their health needs (Doyle, Lennox, & Bell, 2013).The focus on patient experience pushes everyone to recognize the importance of putting patients at the center of all the services provided and decisions being made in a healthcare setting. Patient experience is increasing the focus because it is an indicator of the quality of care and it has been proven to impact patient outcomes, and medical malpractice claims (Doyle et al., 2013). In addition to the quality aspect, patient experience scores are tied to financial incentives from payers (Chernew, Mechanic, Landon, & Sanfran, 2011). The financial incentive pushes the healthcare organization to make effective changes to improve the scores in order to increase their reimbursements. A positive patient experience is also correlated to increasing retention and growth of the organization (Hill, & Doddato, 2002). The increase in volume and demand will allow for the organization to increase their revenue. In order to gauge how patients, feel about their visit to a healthcare site, surveys are sent to gather feedback about their visits. In this paper, the patient experience at UPMC Children’s Hospital of Pittsburgh’s Ambulatory Department will be discussed. UPMC is a large integrated global nonprofit health network located primarily in western Pennsylvania and affiliated with the University of Pittsburgh. It is a healthcare provider and insurer with over 87,000 employees. UPMC has four major divisions including provider services, insurance services, international services, and enterprises. UPMC’s health services includes over 40 hospitals, UPMC Children’s is one of these in addition to being one of the few specialty services hospitals at UPMC. UPMC Children’s was founded in 1890; it was originally located in the Oakland neighborhood of Pittsburgh, but in the early 2000s it recognized a need for a larger space so it relocated in 2009 to Lawrenceville. During fiscal year 2018, UPMC Children’s had over 12,000 inpatient admissions and over one million outpatient visits. UPMC Children’s Hospital is nationally ranked in the U.S. News & World Report consistently. The hospital received Magnet status and is one of only 6 percent of hospitals across America to receive this honor. UPMC Children’s was also the first pediatric hospital to achieve Stage 7 recognition from HIMSS Analytics, which is their highest award for information technology.Consumer assessment of healthcare providers and systems (CAHPS)In 1995, the Agency for Healthcare Research and Quality (AHRQ) launched the Consumer Assessment of Healthcare Providers and Systems (CAHPS) program. AHRQ recognized a lack of readily available information to make effective decisions about a provider or healthcare organization (Goldstein, Farquhar, Crofton, Darby, & Garfinkel, 2005). Most organizations conducted patient satisfaction surveys but they varied from hospital to hospital so there was no standardization. Hospitals were able to change the surveys frequently, which meant there was not a consistent way to compare hospitals to each other. There also were not actionable items as a result of those surveys varying across organizations. The main goals of CAHPS was to develop a more standardized survey that allows organizations to benchmark against each other and also utilize different resources to improve the patient experience throughout the country (Goldstein et al., 2005). The CAHPS survey results are publically reported allowing for patients to view results of all healthcare organizations.The CAHPS surveys are utilized as quality improvement tools in order to track progress and determine areas for improvement. Multiple versions of CAHPS are used based on the setting in which care is provided for the patients (Goldstein et al., 2005). The three most commonly used CAHPS surveys include CAHPS Health Plan Survey, CAHPS Clinical & Group Survey, and CAHPS Hospital Survey. These surveys have versions for adults and children. Individuals who are 18 years of age or older are considered adults and those under 18 are considered children. For the children’s version, it is expected that a parent or guardian will fill it out on the patient’s behalf. Survey DeliveryDue to its size, UPMC has elected to centralize how the surveys are completed. Press Ganey Associates is the third-party vendor that UPMC utilizes to distribute surveys to patients who are seen at UPMC locations. Utilizing Press Ganey allows organizations to gather honest feedback from patients about their visit and relieves the workload for UPMC. The expectation is that all of the providers are enrolled in Press Ganey and Cognos (the reporting tool that UPMC utilizes to display information in an easy-to-read format).After a patient visits a UPMC facility, key patient information is sent to the Donald D. Wolff, Jr. Center for Quality Improvement and Innovation at UPMC (Wolff Center). The Wolff Center assists UPMC providers in ensuring a high quality of care for all of their patients. The Wolff Center then sends the patient records to Press Ganey to survey the patient via email. The patient has 30 days to complete their survey. Once the survey is completed, Press Ganey sends the results to the Wolff Center, which are then uploaded onto the Press Ganey online portal. The results uploaded to Press Ganey are updated in Cognos daily. The Wolff Center reviews all comments to ensure they pertain to the visit and do not contain vulgar language. Enrolled providers receive a scorecard that is sent automatically to their email the third week of every month, which encompasses all of the patient comments and star rating from the surveys. In this scorecard, there is a clear breakdown of the questions that relate to the provider and how they scored. The scores correlates to the national percentile rank, which is created by comparing the provider to all of the other providers who are participating in the CAHPS Clinical Group Survey (CG-CAHPS). ?This scorecard allows the provider to read through the feedback from patients in one document. It is optional for the patients to leave their name and phone number. When you look at this scorecard, you can easily identify in which area the provider may have opportunity to improve and in which categories they are excelling. This allows for a more targeted approach when making interventions. Managers and directors are able to pull the information from Cognos independently. All of the comments are posted to UPMC’s Find a Doc website as long as they are not overtly offensive. The website has a listing of all of the providers within UPMC so that patients can find a provider that fits their needs. This website provides information about the providers including their credentials, past patient experience scores and comments. If a provider feels that the comments are inappropriate, they are able to enter an appeal process. Providers can appeal a comment if it fits into one of the following categories:The comment does not refer to an interaction with the provider;The comment contains a patient’s or family member’s name or any other identifying information or patient health information;The comment contains profanity; orThe comment refers to a provider’s appearance, expressions or accents.The appeals process can take up to six weeks to complete. UPMC’s goal is to upload as many comments to the Find a Doc website in an effort to offer maximum transparency. Literature ReviewCleveland Clinic recognized their efforts to put patients first is lost when the physicians are not engaged with the mission of Cleveland Clinic (Boissy & Gilligan, 2016). Cleveland Clinic implemented communication training for all physicians regardless of level of experience, specialty and patient experience scores. Their strategy to educate all providers regardless of resistance and skepticism. Their goal was to level the playing field with a communication skills training program. They implemented the “R.E.D.E. to Communicate” model that incorporated evidence-based communication skills that can be applied to any conversation. The model uses three phases of Relationships including Establishment, Development and Engagement. Cleveland Clinic trained clinicians through improv, interactive presentations, skills demonstrations, and small group skills practice sessions and discussion. Cleveland Clinic recognized that this training decreased burnout and emotional exhaustion, while increasing patient experience scores. Positive patient experience is created through a culture of service excellence that requires buy-in from the leadership team (Rosen, Burrows & Greenspan, 2016). Providers can receive feedback and coaching from external consultants and internal physician coaches to better understand the expectations from families (Rosen et al., 2016). These coaches shadow the physicians to understand their normal day to day and provide feedback on how they can improve their interactions with the patients and families (Rosen et al., 2016). These coaching methods will impact the questions in the patient experience surveys that reference providers. Access is another domain in the patient experience surveys. This domain encompasses questions that relate to scheduling appointments and wait times when families arrive for visit. It is encouraged that provider’s office offer hours that meet the needs for patients and families instead of a standard business day starting at nine in the morning and closing at five in the afternoon. There should be hours available all day including early morning, afternoons and weekends. Expanding hours will allow for the organization to see more patients and increase retention rates (Morris & Bates, 2014). If patients are unable to schedule appointments, they will look elsewhere for their services. Practices should also incorporate appointments dedicated to open access in their schedules. These blocks will allow for increased access to care because they will be able to see the provider quickly. Another aspect of access is the ability to call a provider’s office with a question and have someone answer the call to address the patient’s needs in real-time. The Studer Group suggests implementing a centralized call center for organizations with high call volumes (Morris & Bates, 2014). Shifting call volume to a call center will allow office staff at the provider offices to focus on the patients that are present without having to juggle a high call volume. It is important to train the call center staff, so they are able to answer the family’s questions without transferring or holding the families. Access takes into consideration patient’s wait times at provider sites. A study at Wake Forest University Baptist Medical Center was conducted to assess how wait times affect patient satisfaction scores (Camacho, Anderson, Safrit, Jones, & Hoffmann, 2006). They recognized that the longer the patient waits, the lower they will rate their provider on surveys. Case Study: UPMC Children’s Hospital of PittsburghUPMC Children’s Hospital has a robust Ambulatory Department, which sees hundreds of patients every day at its main campus, satellite and outreach locations. This department utilizes the CG-CAHPS, which is the survey formatted for healthcare providers and staff within a doctor’s office. The department receives over 1,000 patient experience surveys a month from all of the medical practices combined. The Ambulatory Department leadership team consists of a Vice President, two Senior Directors, three Division Administrators and two Directors of Operations who oversee all of the outpatient activity. This leadership team is responsible for thepatient experience work and accountable for the scores, and ultimately the patient’s experience at their institution. Current ScoresAt UPMC Children’s Hospital there is a focus on increasing the percentile rank in patient experience scores, which compares the hospital to all of the other hospitals in the country. This is a complex goal to achieve because the percentile is constantly shifting based on how the other all hospitals in the country are scoring.Figure 1 displays UPMC Children’s Hospital Ambulatory Department’s scores from January 1, 2018, to December 31, 2018. The graph displays responses to six questions or categories from the survey. Note that all of the percentages range between 74.2 to 93.5 but the percentile rank ranges from 6 to 65. From this graph, it is noted that the three lowest categories are office staff quality, access to care and care coordination.Figure 1: CY 2018 Patient Experience ScoresIn addition to the questions, the patients and families are able to leave comments about their visit. The comments indicate that there are long wait times until an appointment can be scheduled, as well as a delay in being seen once patients have arrived at the scheduled appointment. Those comments contribute to the access to care category and need to be considered when making suggestions for improvements. Current initativesWait TimesCurrently, in healthcare there is an increase of volumes in the outpatient setting. Long wait times have consistently been a challenge as the demand for the ambulatory services has grown over time. In an effort to reduce wait times, UPMC Children’s is assessing space in an effort to increase space utilization so that providers can see patients in a timely manner. Space utilization impacts hospital operations on a regular basis and it is important to make changes as needed to ensure that there is enough room for all the patients who are scheduled. Outpatient visits are becoming more complex in nature and hospitals need to make sure that they can keep up with the demands. Efficient utilization of exam rooms is important because it saves the organization money by allowing the resources allocated to be utilized to their fullest capacity. After assessing space utilization, changes are being piloted in order to expedite patient flow. One of the many changes is to stagger appointment times. As it stands several providers in each of the clinics start their appointments at the same time, which makes it difficult for the medical assistants and nursing staff to assess and room the patients on time. The lack of staff as well as space creates a bottleneck in the appointment process. To address this, UPMC Children’s Ambulatory Department is in the process of smoothing out patient arrival patterns. Delayed patient rooming also delays the providers from seeing the patient, which will then push back when they can see the next patient. It is a vicious cycle and results in a negative patient experience because of the long wait times it creates. When providers start their appointments at different times it allows the front-line staff to room the patients and take their vitals without a lag. It is as simple as starting some providers 15 minutes earlier than the rest of the providers so that there is a consistent patient flow throughout the day. For example, if there are three providers working at once, their appointment times would be staggered between 7:45 and 8:15 in the morning instead of starting all at 8:00. This has little to no impact on the provider because they can still see the same number of patients within the same time frame. Staggering appointments will also reduce the stress on the front-line staff because they will be able to work at a consistent pace without the additional pressure of patients waiting to be taken to their exam room. The leadership team is collaborating with the different divisions to adjust schedules but it is still in the initial stage of implementation. ScribesAnother common theme in healthcare is provider burnout due to the increase in documentation required by the electronic medical record. Each provider has their own preference in regards to whether they document during the visit, immediately after or after all of the patients are seen for the day. If a provider is completing the documentation right after their visit, it causes delays in seeing the next patient from being seen because as it stands the providers do not have gaps in their schedule to catch up on documentation. UPMC Children’s is currently piloting the use of scribes within their busy outpatient practices. The scribes go through an extensive training to understand the expectations of the providers as well as the regulations behind documentation. The goal of using scribes is to assist with documentation so that providers are able to quickly move from patient to patient without having to take notes during the patient encounter. This will ideally provide a positive patient experience because it allows for more eye contact and less time on the computer. The provider will be able to dedicate more time to that patient and their families instead of having to document during the encounter. Some providers finish documentation at home, which takes away time from their personal life and can contribute to poor work-life balance. Utilizing scribes can be beneficial in regards to increasing patient satisfaction and reducing physician burnout. Another benefit is allowing the providers to work to the top of their licensure because it minimizes non-value added time. However, from an administrative point of view, if scribes are able to assist with documentation then providers are able to increase their patient volumes. There needs to be clear justification for the financial impact of the scribes. Currently, scribes are being utilized within four divisions with their high-volume providers. The scribes are being cross trained in the different divisions so that they can backfill as needed. This training will be beneficial because the scribes will be able to shift to providers that have high volumes or behind on their appointments. This will decrease wait times and improve provider work flow because providers will be able to move from patient to patient without the hassle of documentation between the appointments. Call CenterAnother issue that was shared in the comments was that patients were not able to schedule appointments in a timely manner. The leadership team recognized that patients were calling in to schedule an appointment but the practices were often unable to answer in a timely manner due to competing priorities. When patients are unable to schedule an appointment at the time that they need, they may not return to that practice or may experience a delay in care. UPMC Children’s Hospital implemented a centralized call center that allows families to call one center for scheduling all of their appointments instead of contacting multiple departments. UPMC Children’s call center went live in July 2017 using a phased approach in an effort to allow all of the divisions to fully integrate the changes. When the call center was created, the administration requested that individuals who schedule for the divisions switch over to become a part of the corporate call center. This took employees away from the divisions and their normal schedule, but it allowed for all of the employees to go through similar training to prepare them for their role. Since it is a centralized system, all of the schedulers assist with every division to provide cross-coverage. One of the benefits of this cross-coverage is that patients are always able to connect with a CHP employee when they call. However, there are challenges with the cross-division model as well such as the complexity and specificity of the patient needs. Many patients have complicated issues that cannot always be easily scheduled with a high degree of accuracy. Although there is a training available for call center staff, it is difficult to train them on the intricacies of over 25 medical sub-specialties. Outcomes can be improved over time with simplification of the scheduling templates, additional education and logical protocols. Provider Gap AnalysisDuring the author’s analysis, it was found that a significant portion of providers were not enrolled in Cognos or Press Ganey, which meant that those providers did not have surveys sent on their behalf to the patients that they treated. This means that providers are not receiving feedback from the patients as they normally would if they were enrolled in both systems. This issue came from confusion over who was responsible for enrolling the providers into these systems. The expectation is that the practice managers enroll the providers into these systems using a form that the Wolff Center distributed, but an important second step in the process is to follow up and ensure that the provider is indeed receiving the provider scorecard. Due to the manual nature of this process providers often were improperly enrolled or accidentally omitted from one of the systems. During the analysis, it was determined that over 80 providers were missing from Cognos and/or Press Ganey. This analysis also allowed the department to enroll their advance practice providers onto the systems. In the past, many advance practice providers (physician assistants and nurse practitioners) were not receiving any feedback. Through the gap analysis, the department was able to identify providers that were missing to increase the amount of surveys collected. Increasing the amount of surveys sent to families, will allow for more feedback and provide more accurate results. In a recent study, higher response rates have been correlated to higher scores on the patient experience survey (Saunders, Elliott, Lyratzopoulous, & Abel, 2016). Patient Experience ReportingAnother primary goal of UPMC Children’s Hospital is to share patient experience results more consistently with the key stakeholders. These stakeholders include the providers, practice managers, clinical directors, chiefs and ambulatory leadership team. In the past, the practice leadership was required to access and run their own reports, or wait for a centralized patient experience manager to run custom reports on their behalf. Because of the extra effort required to obtain this information, comments that the patients wrote at the end of the survey or even the results were not regularly shared. These reports were done in various ways depending on who ran them and when, making it difficult to track and trend the data over time. The importance of the data was also lost because it was not regularly reported and shared and therefore not seen as a high priority. The Ambulatory Department receives over 1000 surveys every month across all of the Ambulatory Department divisions. It is important for the department to take the time to understand the feedback from the families. UPMC Children’s started sending out biweekly comment reports in 2017, and in 2018 expanded the dataset to include monthly reports that laid out the data for each of the domains and compared them to past months. Figure 2 is an example of the chart that is distributed to the key stakeholders. The graph above shows the percentage and percentile of patients that rated heir provider at a 9 or 10. The double-sided bar graph was utilized because it displays both the percentage and percentile. The bars represent the percentage, while the line is the percentile rank. This graph shows that June 2018 was a strong month for the Ambulatory Department, while October 2018 was its lowest. Figure 2: Overall Doctor Rating of 9 - 10 graphIn addition to the overall monthly report, there is a specialty specific report that compares the different specialties to each other. This report allows for the department to compare the divisions to understand where to target their efforts or understand if there are consistent trends between all of the departments. The key stakeholders are expected to regularly review the reports to find areas for improvement.AIDET Plus the PromiseThe AIDET acronym stands for Acknowledge, Introduce, Duration, Explanation, and Thank you (Morris, Hotko, & Bates, 2015). AIDET is also referred to as the Five Fundamentals of Communication (Morris, et al., 2015). Acknowledge is taking the time to greet everyone with a smile and use their names. The next step is to introduce oneself to patients. ?This will allow them to know one’s role, as well as one’s credentials. For example, a laboratory technician mentioning their 20 years of experience may provide a modicum of reassurance to the patient that the technician will provide proper care. In the duration step, the caregiver explains the approximate length of the encounter. The last step is to incorporate a “thank you” for allowing the organization to provide the care as well as a promise in regards to next steps. Implementing AIDET can improve the patient experience because it will provide comfort and reassurance and sets the expectations for the remainder of their care. The promise was added to AIDET because it allowed the caregiver and families to form a stronger bond. UPMC is collaborating with the Studer Group to implement AIDET Plus the Promise. The Studer Group is an external consulting group that assists with patient experience through different trainings. AIDET Plus the Promise is a framework for staff to communicate with patients and families (Morris, et al., 2015). This AIDET framework is used by staff for the provision of information and assurance to the patient. For example, imagine a laboratory technician walking into a room and not taking the time to explain to the patient who they are, what they are doing, and how long it will take for the blood draw. Utilizing AIDET will improve patient perception of care, reduce anxiety, and build patient loyalty (Scott, 2012). RecommendationsUPMC Children’s is attempting to make effective changes in the future in regards to improving the patient experience but like many institutions, there is still opportunity to improve. The author was able to observe the Ambulatory Department over a 15-month period and came up with opportunities that the department can work on to improve the patient experience for their families. Patient Experience CoachPatients want to have a relationship with their provider and therefore the majority of the survey questions ask about the patient’s relationship with that particular provider, such as if the patient felt as if the provider spent enough time with them, if they listened carefully and if they followed up on care. It is important to support providers and provide them with strategies to ensure that they are meeting the expectations of the patients. One recommendation is to target the physicians who scored the lowest and have an individual that focuses on patient experience shadow them for a day. This patient experience coach will observe the provider and understand what their patients are experiencing during their visit. The patient experience coach will provide suggestions for the provider to utilize moving forward. This is a targeted effort and more time consuming since the patient experience coach would have to spend time with each individual provider. It would be beneficial for the organization to hire external consultants so they are able to provide unbiased feedback during the sessions. This method would be useful with providers who are rated lower, and new providers. Leadership RoundingCurrently, at UPMC Children’s Hospital, the leadership (director level or higher) takes time to walk around and talk to their employees about their experience. This process is referred to as rounding. Typically, the leaders have targeted questions during their rounds. Moving forward, there should be rounding on the patients more regularly. Leadership can identify clinics that are often running behind and visit them to understand why and talk to the patients to provide support and conduct service recovery. This rounding will help identify changes for those particular clinics in order to help them run more efficiently, whether it is allowing more time for a buffer or scheduling the patients in a particular order. It also improves the patient experience when leaders are actively rounding and accessible to answer questions as they come up. In addition, depending on the hospital budget but it might be a nice addition for leaders to round and bring treats such as beverages and snacks to enjoy during the wait. For the patients with diet restrictions, they can incorporate activities that can be done in the reception area with the child life volunteers. This technique could be particularly effective in pediatric waiting rooms because children tend to be more impatient. Rounding on patients reassures the patient that they are not forgotten and makes the wait more tolerable with additional attention. Rounding is a proactive approach that will also reduce the amount of complaints from the families (Petras, Dudjak, & Bender, 2013). Increase Front Line Staff EngagementThe front-line staff (registrars, medical assistants and clinic nurses) play a large role in the patient experience and it is important that they are engaged. The office staff receive the lowest ratings within the Ambulatory Department. The office staff tend to be stretched thin and it is hard to stay motivated over time. There needs to be a culture of teamwork and collaboration. When a medical assistant or nurse rooms the patient, they let the provider know the patient is ready by either dropping off a form at the provider’s workstation or marking the board, depending on the practice. Moving forward, the office staff should work more collaboratively to ensure that clinic runs smoothly for everyone. The providers and office staff should have regular meetings to discuss how they are going to make the clinic flow better moving forward. They can talk about any concerns that occur in clinic and come up with innovative solutions as a team. This will require more administrative time for the office staff and providers but it can make for a more positive work environment and help with the care coordination aspect as well. Patient experience scores are affected by the culture. Patients are able to sense negative attitudes and will take that into consideration when they are completing the survey (Shortell, Schmittdiel, Wang, Li, Gillies, Casalino, Bodenheimer, & Rundall, 2005). Improving the culture of the department will also help with employee turnover and retention (Baum, & Homisakt, 2013). Setting ExpectationsAn important aspect to creating a change is setting expectations. Regularly reporting patient experience is a good place to begin because it gives the employees an understanding of where the Ambulatory Department stands comparison to the other hospitals across the country. Since there are more data readily available, the leadership team can set expectations for the different divisions. They should encourage each division to increase their percentage or percentile ranking by a certain amount each year. These scores should be addressed in leadership meetings so that everyone is aware of the progress. At this point, the Ambulatory Department is just sharing the data and allowing each group to do with it what they choose. Administrative leaders, providers and registration staff all have different reporting structures and have different expectations. It is essential for the group to standardize the expectations and keep everyone accountable. Annually, the leaders of the Ambulatory Department come together for a retreat. The retreat is normally held at the end of the calendar year, this meeting can be used to set goals and expectations for the team moving forward. The forum will allow for representatives from each specialty to voice opinions and collaborate to set realistic goals. The leaders will then be able to share the expectations with their team to ensure that it is uniform throughout the department. ConclusionOver time, a lot of work has been focused on improving the patient experience. The CAHPS program allows healthcare providers to receive meaningful feedback from their patients and allows them to understand how they compare to other hospitals. A good experience has been linked to higher quality care. Given the changes in healthcare, it is important that all healthcare organizations assess their current scores and try to increase them moving forward to improve the visit for their patients. Healthcare organizations need to make effective changes to improve the patient experience since organizations are publically compared. The national percentile rank changes so it is vital for organizations to make patient experience a priority. UPMC Children’s Hospital is innovative and has been working on a variety of initiatives that other hospitals would want to recreate down the line. They are addressing feedback from the patients and families to make effective changes. Through their data, they know they have room for improvement and are making the patient experience a priority. All of their current initiatives including medical scribes, room utilization, and centralized call center have been proven at other organizations to make an impact on providers and families. It is recommended that the hospital incorporate patient experience coaches, leadership rounding, improve staff engagement and set expectations to improve their scores. UPMC Children’s Hospital’s leadership team recognizes that there are still opportunities for growth and are engaging with external consultants to learn more about the different techniques that can be used to improve. One of the limitations of this analysis is that it takes months to see any changes in patient experience scores. The survey results are limiting because they are normally completed by caregivers instead of patients. There is a response bias because it is an optional survey that is completed through the internet. Regardless of the bias, the patient experience scores are correlated to quality and increased reimbursements for services. It is essential for hospital leadership teams to assess room for improvement and make changes that will decrease clinician burnout and allow for all levels of employees to collaborate to provide the best experience possible. bibliographyBaum, Neil, and Lynn Homisakt. “Is Your Glass Half Full or Half Empty? Your Decision May Impact Your Practice.” The Journal of Medical Practice Management : MPM, U.S. National Library of Medicine, 2013, ncbi.nlm.pubmed/24228374.Boissy, A., & Gilligan, T. (2016). Communication the Cleveland Clinic way: How to drive a relationship-centered strategy for exceptional patient experience. New York: McGraw-Hill Education.Camacho, F., Anderson, R., Safrit, A., Jones, A. S., & Hoffmann, P. (2006). The Relationship between Patient’s Perceived Waiting Time and Office-Based Practice Satisfaction. NCMedJ, 67(6), 409-413. Retrieved April 15, 2019.Chernew, Michael, et al. “Private-Payer Innovation In Massachusetts: The 'Alternative Quality Contract'.” Health Affairs, Jan. 2011, doi/10.1377/hlthaff.2010.0980.Doyle, C., Lennox, L., & Bell, D. (2013). The CG CAHPS Handbook: A Guide to Improve Patient Experience and Clinical Outcomes. BMJ Open. Retrieved April 15, 2019.Goldstein, E., Farquhar, M., Crofton, C., Darby, C., & Garfinkel, S. (2005). Measuring Hospital Care from the Patients Perspective: An Overview of the CAHPS? Hospital Survey Development Process. Health Services Research, 40(6p2), 1977-1995. doi:10.1111/j.1475-6773.2005.00477.xHill, Mary H, and Theresa Doddato. “Relationships among Patient Satisfaction, Intent to Return, and Intent to Recommend Services Provided by an Academic Nursing Center.” Journal of Cultural Diversity, U.S. National Library of Medicine, 2002, ncbi.nlm.pubmed/12674887.Morris, J., Hotko, B., & Bates, M. (2015). The CG CAHPS handbook: A guide to improve patient experience and clinical outcomes. Pensacola, FL: Fire Starter Publishing.Petras, Denise, et al. “Piloting Patient Rounding as a Quality Improvement... : Nursing Management.” LWW, July 2013, journals.nursingmanagement/Fulltext/2013/07000/Piloting_patient_rounding_as_a_quality_improvement.5.aspx.Rosen, P., Burrows, J. F., & Greenspan, J. S. (2016). Physician Engagement in the Transformation of the Pediatric Patient?Experience. The Journal of Pediatrics, 169, 4-5. doi:10.1016/j.jpeds.2015.11.023Saunders, Catherine, et al. “Do Differential Response Rates to Patient Surveys Between... : Medical Care.” LWW, Jan. 2016, journals.lww-medicalcare/FullText/2016/01000/Do_Differential_Response_Rates_to_Patient_Surveys.9.aspx.Scott, J. “Utilizing AIDET and other tools to increase patient satisfaction scores.” Radiol Manage, U.S. National Library of Medicine, Jun. 2012, , Stephen M, et al. “An Empirical Assessment of High-Performing Medical Groups: Results from a National Study.” Medical Care Research and Review : MCRR, U.S. National Library of Medicine, Aug. 2005, ncbi.nlm.pubmed/16049132. ................
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